Australian National Child Digital Health Implementation Guide

National Child Digital Health Implementation Guide, published by National Children's Digital Health Collaborative (NCDHC). This is not an authorized publication; it is the continuous build for version null). This version is based on the current content of https://github.com/hl7au/au-fhir-childhealth/ and changes regularly. See the Directory of published versions

For POC Use

SD.47 StructureDefinition-ncdhc-observation-anus

NCDHC Anus Observation Profile

This profile sets minimum expectations for the [Observation] resource to record, search and fetch anus assessment outcome of the child. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile. The profile is at draft stage and under review by the Child Health Working Group.

Example Usage Scenarios:

The following are example usage scenarios for the National Child Digital Health interactions profile:

  • Query for anus assessment outcome of the patient
  • Record anus assessment outcome of the patient
Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Observation must have:

  1. a status
  2. a SNOMED code (indicating what was recorded)
  3. a subject (Patient)
  4. a time (indicating when the details were recorded)
  5. a performer (detailing who has recorded the details)

Examples

SD.47.1 Formal Views of Profile Content

The official URL for this profile is:

http://hl7.org.au/fhir/ch/v1/StructureDefinition/ncdhc-observation-anus

Anus Outcome

This profile builds on NCDHCObservationBaseProfile.

This profile was published on Fri Feb 15 00:00:00 UTC 2019 as a draft by National Children's Digital Health Collaborative (NCDHC).

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Observation must have:

  1. a status
  2. a SNOMED code (indicating what was measured)
  3. a subject (Patient)
  4. a time (indicating when the details were taken)
  5. a performer (detailing who has recorded the details)

*Refer to the Base Profile: NCDHC Observation Base Profile for base rules that are applied in this profile.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*NCDHCObservationBaseProfileNCDHC Anus Test Observation Profile
... code S1..1CodeableConceptType of observation (code / type)
.... coding 0..*(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by pattern:code, value:system
..... coding:AnusSNOMED-CT 1..1CodingCode defined by a terminology system
Required Pattern: At least the following
...... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 364154000
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1codeSymbol in syntax defined by the system
... subject 1..1Reference(NCDHC Patient Baby)Reference to the Baby Patient
... effectiveDateTime:effectiveDateTime 0..1dateTimeDate when Anus assessment was performed
... valueCodeableConcept:valueCodeableConcept 0..1CodeableConceptActual result
Binding: NCDHC Observation Completion Status (required)
... interpretation 0..1CodeableConceptNormal | Review | Refer
Binding: NCDHC Observation Interpretation (required)
... comment 0..1stringAdditional comments

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*NCDHCObservationBaseProfileNCDHC Anus Test Observation Profile
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
Max Binding: All Languages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest)Fulfills plan, proposal or order
... status ?!SΣ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category S0..1CodeableConceptClassification of type of observation
Binding: NCDHC Observation Category (required)
... code SΣ1..1CodeableConceptType of observation (code / type)
Binding: LOINC Codes (example)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by pattern:code, value:system
..... coding:AnusSNOMED-CT Σ1..1CodingCode defined by a terminology system

Required Pattern: At least the following
...... id0..1stringxml:id (or equivalent in JSON)
...... extension0..*ExtensionAdditional Content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 364154000
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(NCDHC Patient Baby)Reference to the Baby Patient
... context 0..1Reference(Encounter | EpisodeOfCare)Healthcare event during which this observation is made
... effective[x] Σ0..1(Slice Definition)Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime SΣ0..1dateTimeDate when Anus assessment was performed
... issued Σ0..1instantDate/Time this was made available
... performer Σ2..*Reference(AU Base Organisation | AU Base Practitioner)Person and Organisation who is clinically responsible for the undertaking of the examination/assessment
... value[x] ΣI0..1(Slice Definition)Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueCodeableConcept ΣI0..1CodeableConceptActual result
Binding: NCDHC Observation Completion Status (required)
... dataAbsentReason SI0..1CodeableConceptWhy the result is missing
Binding: NCDHC Observation Value Absent Reason (extensible)
... interpretation 0..1CodeableConceptNormal | Review | Refer
Binding: NCDHC Observation Interpretation (required)
... comment 0..1stringAdditional comments
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMED CT Body Structures (example)
... method 0..1CodeableConceptHow it was done
Binding: Observation Methods (example)
... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange I0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: Observation Reference Range Meaning Codes (extensible)
.... appliesTo 0..*CodeableConceptReference range population
Binding: Observation Reference Range Applies To Codes (example)
.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... related ΣI0..*BackboneElementResource related to this observation
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1codehas-member | derived-from | sequel-to | replaces | qualified-by | interfered-by
Binding: ObservationRelationshipType (required)
.... target 1..1Reference(Observation | QuestionnaireResponse | Sequence)Resource that is related to this one
... component ΣI0..*BackboneElementComponent results
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINC Codes (example)
.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueAttachmentAttachment
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: Observation Value Absent Reason (extensible)
.... interpretation 0..1CodeableConceptHigh, low, normal, etc.
Binding: Observation Interpretation Codes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result

doco Documentation for this format
Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Observation must have:

  1. a status
  2. a SNOMED code (indicating what was measured)
  3. a subject (Patient)
  4. a time (indicating when the details were taken)
  5. a performer (detailing who has recorded the details)

*Refer to the Base Profile: NCDHC Observation Base Profile for base rules that are applied in this profile.

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*NCDHCObservationBaseProfileNCDHC Anus Test Observation Profile
... code S1..1CodeableConceptType of observation (code / type)
.... coding 0..*(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by pattern:code, value:system
..... coding:AnusSNOMED-CT 1..1CodingCode defined by a terminology system
Required Pattern: At least the following
...... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 364154000
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1codeSymbol in syntax defined by the system
... subject 1..1Reference(NCDHC Patient Baby)Reference to the Baby Patient
... effectiveDateTime:effectiveDateTime 0..1dateTimeDate when Anus assessment was performed
... valueCodeableConcept:valueCodeableConcept 0..1CodeableConceptActual result
Binding: NCDHC Observation Completion Status (required)
... interpretation 0..1CodeableConceptNormal | Review | Refer
Binding: NCDHC Observation Interpretation (required)
... comment 0..1stringAdditional comments

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*NCDHCObservationBaseProfileNCDHC Anus Test Observation Profile
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
Max Binding: All Languages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest)Fulfills plan, proposal or order
... status ?!SΣ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category S0..1CodeableConceptClassification of type of observation
Binding: NCDHC Observation Category (required)
... code SΣ1..1CodeableConceptType of observation (code / type)
Binding: LOINC Codes (example)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by pattern:code, value:system
..... coding:AnusSNOMED-CT Σ1..1CodingCode defined by a terminology system

Required Pattern: At least the following
...... id0..1stringxml:id (or equivalent in JSON)
...... extension0..*ExtensionAdditional Content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 364154000
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(NCDHC Patient Baby)Reference to the Baby Patient
... context 0..1Reference(Encounter | EpisodeOfCare)Healthcare event during which this observation is made
... effective[x] Σ0..1(Slice Definition)Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime SΣ0..1dateTimeDate when Anus assessment was performed
... issued Σ0..1instantDate/Time this was made available
... performer Σ2..*Reference(AU Base Organisation | AU Base Practitioner)Person and Organisation who is clinically responsible for the undertaking of the examination/assessment
... value[x] ΣI0..1(Slice Definition)Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueCodeableConcept ΣI0..1CodeableConceptActual result
Binding: NCDHC Observation Completion Status (required)
... dataAbsentReason SI0..1CodeableConceptWhy the result is missing
Binding: NCDHC Observation Value Absent Reason (extensible)
... interpretation 0..1CodeableConceptNormal | Review | Refer
Binding: NCDHC Observation Interpretation (required)
... comment 0..1stringAdditional comments
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMED CT Body Structures (example)
... method 0..1CodeableConceptHow it was done
Binding: Observation Methods (example)
... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange I0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: Observation Reference Range Meaning Codes (extensible)
.... appliesTo 0..*CodeableConceptReference range population
Binding: Observation Reference Range Applies To Codes (example)
.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... related ΣI0..*BackboneElementResource related to this observation
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1codehas-member | derived-from | sequel-to | replaces | qualified-by | interfered-by
Binding: ObservationRelationshipType (required)
.... target 1..1Reference(Observation | QuestionnaireResponse | Sequence)Resource that is related to this one
... component ΣI0..*BackboneElementComponent results
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINC Codes (example)
.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueAttachmentAttachment
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: Observation Value Absent Reason (extensible)
.... interpretation 0..1CodeableConceptHigh, low, normal, etc.
Binding: Observation Interpretation Codes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

SD.47.2 Quick Start

Below is an overview of the requirements for search and read operations.